| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Program Specialist #1, date of hire 2/9/2024, had a Pennsylvania criminal history check completed on 2/21/2024. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.
| In order to correct this violation, on November 22nd the Human Resources staff was retrained on the importance of completing background checks and ensuring that no offer letters are sent until all required clearances, including Pennsylvania criminal history checks, have been received. This retraining emphasized the need for strict pre-employment requirements. Additionally, the Program Coordinator reviewed all current staff files to confirm that all required clearances are up to date |
11/22/2024
| Implemented |
| 6400.113(a) | Individual #1 was trained in general fire safety training on 2/9/2023, and then again on 2/26/2024. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | In order to correct this violation, on November 21, 2024, the Program Specialist was retrained on the admission process to ensure that all required fire safety training is completed and properly documented within the required timeframe. The retraining emphasized the importance of timelines for fire safety instruction and maintaining accurate records. Individual #1's fire safety training, completed on February 9, 2023, and February 26, 2024, was reviewed during the retraining session and used as an example to reinforce proper procedures and documentation practices. |
11/21/2024
| Implemented |
| 6400.141(c)(11) | Individual #1's physical examination completed 3/14/2024 did not include the medication regimen for the individual. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | In order to correct this violation, Individual #1's physical examination form from March 14, 2024, was reviewed, and the missing medication regimen was promptly added on November 18th, 2024. The updated physical examination now includes a complete and accurate record of Individual #1's current medication regimen. |
11/18/2024
| Implemented |
| 6400.151(a) | Program Specialist #1, date of hire 2/9/2024, had an initial physical examination on 2/23/2024. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | In order to correct this violation, the Human Resources staff was retrained on November 21, 2024, on the importance of ensuring that all pre-employment requirements, including physical examinations, are completed and documented before an offer letter is sent. This retraining emphasized the critical need for timelines and ensuring compliance. Additionally, the Program Coordinator conducted a thorough review of all current staff files to confirm that all required physical examinations and clearances are up to date. |
11/21/2024
| Implemented |
| 6400.151(c)(2) | Program Specialist #1, date of hire 2/9/2024, had an initial Tuberculin test by Mantoux method on 2/23/2024. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | In order to correct this violation, the Human Resources staff was retrained on November 21, 2024, to ensure that all pre-employment requirements, including Tuberculin testing by the Mantoux method, are completed and documented before an offer letter is issued. This retraining emphasized the importance of timelines and ensuring compliance. Additionally, the Program Coordinator reviewed all current staff files to confirm that all required Tuberculin tests and other pre-employment requirements are up to date. |
11/21/2024
| Implemented |
| 6400.34(a) | Individual #1 was informed and explained individual rights on 2/9/2023 and then again on 2/26/2024 | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | In order to correct this violation, on November 21, 2024, the Program Specialist was retrained on the admission process to ensure that all required explanations of individual rights are completed and properly documented within the required timeframe. This retraining emphasized the importance of timelines for informing individuals of their rights and maintaining accurate records. Individual #1's rights explanation, completed on February 9, 2023, and again on February 26, 2024, was reviewed during the retraining session and used as an example to reinforce proper procedures and documentation practices |
11/21/2024
| Implemented |
| 6400.44(c)(1) | Program Specialist #1, date of hire 2/9/2024, did not have the work experience required for the program specialist position. | A program specialist shall have one of the following groups of qualifications: A master's degree or above from an accredited college or university and 1 year of work experience working directly with individuals with an intellectual disability or autism. | In order to correct this violation, immediately the Program Specialist, hired on February 9, 2024, who holds a master's degree and one year of experience as a Behavioral Specialist, will work directly with experienced staff currently qualified for the Program Specialist position. These experienced staff members will temporarily assume the Program Specialist duties while mentoring and training the Program Specialist to help her gain the required work experience. This arrangement ensures that all responsibilities are fulfilled by staff who meet the regulatory requirements for the position, while also supporting the new hire's development. |
11/07/2024
| Implemented |